Provider Demographics
NPI:1861505612
Name:FLORIDA OCULAR PROSTHETICS INC
Entity Type:Organization
Organization Name:FLORIDA OCULAR PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:HARDWICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-221-0929
Mailing Address - Street 1:967 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3702
Mailing Address - Country:US
Mailing Address - Phone:772-221-0929
Mailing Address - Fax:772-221-0939
Practice Address - Street 1:967 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3702
Practice Address - Country:US
Practice Address - Phone:772-221-0929
Practice Address - Fax:772-221-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003223100Medicaid
R9719OtherBC BS
FL003223100Medicaid